PostOperative ManagementComplications

Tracheostomy

Ajay JainRoll No.- 11 Batch:13

North DMC Medical College & HRH

Post Operative Management

Constant Supervision

Mobilisation of Secretions

Tracheostomy Tube Care

Patient & Caregiver Education

Constant SupervisionRequired after shifting to Post-operative Ward.

Specialist nurse should be in attendance.

Tracheostomy kit should be present at the patient’s bedside.

Essential to look for proper placing and patency.

Bell or writing material are provided to communicate.

Bedside Tracheostomy KitTracheostomy tube of the same size and type currently in place

Tracheostomy tube 1 size smaller than the one currently in place

Obturator

Suction catheters (usually 12F or 14F)

Functional suctioning system

Manual resuscitation bag and oxygen

Endotracheal tube of appropriate size

Tracheostomy cleaning kit

Disposable inner cannulas (not required for single-cannula tubes)

10-mL syringe (not required for cuff less tubes)

Tracheostomy holder or ties

Drain sponges

Hydrogen peroxide

Physiological saline

Intubation equipment

Oxygen source

SwallowingSwallowing problems due to: • Tube limit the normal movement of larynx during

swallowing.• Overinflation of cuff can cause pressure sensation in

upper esophagus.Flexible nasoendoscope passed through the tube to visualize the distal end following tracheostomy.

Mobilisation of Secretions

Adequate hydration

Physical mobility

Removal of secretions

Adequate HydrationAir enters trachea directly -> is irritant to trachea -> increase in production & viscosity of secretions.Adequate hydration thus necessary to keep secretions thin & mobile, and prevent crusting.For hospitalised patients, humidity provided by heat & moisture exchanger, a T-piece, tracheostomy mask ,or a ultrasonic nebuliser.At home by keeping a boiling kettle in the room.To loose crusts, drops of NS or RL instilled into trachea 2-3 hrly or use of mucolytic agents to liquify tenacious secretions.

Physical Mobility

Deconditioning in ICU can be prevented with regular physical mobility.A program of progressive mobility, combined with range-of-motion exercises of upper extremeties help in mobilizing secretions.Having the patient sit helps maintain a position of function; the diaphragm is used more effectively, allowing a more effective cough.

Removal of Secretions

Achieved by suctioning and allowing the patient to cough.Suction depends on amount of secretion.When cough strength is less than 15 mL/kg, or the cough reflex is diminished, more frequent suctioning may be required.Suction catheters with Y connector to break suction force.Apply suction to catheter while withdrawing to prevent tracheal mucosa injuries.

Tracheostomy Tube CareChange tracheostomy tube on or after 3rd postoperative day to

allow stoma tract to form. Premature change results in recoiling of dilated stoma tract tissues. Tube secured with sutures until the first tube change, thereafter done with tapes in neck neutral position.Indications for changing tracheostomy tube:

• need for a different size tube• tube malfunction• need for a different type of tube• routine changes for ongoing airway management &

prevention of infection. Replace ties to avoid inadvertent dislodgement of the tracheostomy tube.When the new ties are secure, 2 fingers should fit between the tie and the neck.

Confuse with cuffs?Provide a closed system to prevent aspiration; allow effective ventilation and/or airway protection.

Under inflation promotes leakage of secretions around cuff causing ventilator-associated pneumonia.Overinflation causes tracheomalacia, tracheoinnominate artery fistula, tracheal ulcerations, fibrosis, tracheal stenosis, and tracheoesophageal fistula.Cuff should be deflated every 2hrs for 5min ideally.Use of tubes with two cuffs; alternate inflations on one side of trachea.

Inner cannulaPrevent tube obstruction by allowing regular cleaning or replacement.Clean with a solution of full or half-strength hydrogen H2O2 & NS.Clean atleast 3 times a day, depending on the volume and thickness of patient’s secretions.

Cleansing StomaStoma should be cleaned everyday carefully without dislodging tube.Cotton-tipped swabs or gauze pads with NS applied in semicircular motion, inward to outward.Dried secretions loosened with diluted H2O2 & rinsed with NS.

Patient and Caregiver Education

Utmost important in preventing complications.

Taught to perform basic care of tracheostomy.

Assessment & evaluation of their competency in caring; and home care instruction manual of tube be given before the patient is discharged.

Possible home emergencies should be discussed.

Complications

Immediate

Intermediate

Late

Immediate(at the time of operation)

Anaesthetic complications

Haemorrhage

• most common complication; fatal;

• indicates that the site should be explored, & a vessel may require ligation

Aponea

• due to CO2 washout; administer 5% CO2 in oxygen.

Air embolism

• large neck veins get inadvertently opened; air can be sucked in right atrium

Blood aspiration

Local damage

• thyroid cartilage

• cricoid cartilage

• recurrent laryngeal nerve

• oesophagus : Tracheo-esophageal fistula

• lung apical pleura : Pneumothorax

Intermediate(during first few hours or days)

Bleeding, reactionary or secondary

Displacement of tube

Tube obstruction

Surgical emphysema

Local infections: perichondritis; tracheitis; tracheobronchitis

Atelectasis; Lung abscess

Granulations

Late(with prolonged use for weeks & months)

Laryngeal stenosis : due to perichondritis of cricoid cartilage

Tracheal stenosis : due to tracheal ulceration & infection

Tracheo-esophageal fistula : due to cuffed tube erosion of trachea

Decannulation

Keloid; Disfigured scar

Tube corrosion

Aspiration of tube fragments

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